FUEL4U Adult Questionnaire

Client confidentiality will be maintained at all times. Please allow 30-45 minutes to complete this questionnaire.

Basic Information

Primary Physician's Name

Physician Office Number

Physician Address

Physician Fax Number

Today's Date

Contact Information

Name

Address

Work Phone

Home Phone

Mobile Phone

Preferred Contact Method

Best Time(s) of Day to Reach You

Emergency Contact (Name, Relationship, Phone)

Occupation & Interests

Occupation

What are your interests/passions?

Demographics

Date of Birth

Gender

Ethnicity

Height

Highest Adult Weight

Lowest Adult Weight

Relationship Information

Status

Partner's Name

Partner's Gender

Personal Information

Religion

Education

With whom (persons or animals) do you share your home?

What types of health practitioners are you currently working with?

Primary Reasons for Visiting a Nutritionist

Reason 1

Reason 2

Reason 3

Medical Information

Health concerns experienced as a child

Health concerns experienced as an adult

Diagnosed medical conditions

Recovery program (if applicable)

Allergies (foods, medications, chemicals, environmental)

Typical reaction and severity (1-10)

Surgeries/operations (what and when)

Hospitalizations (when and why)

Major chemical exposure (when and what)

Lived or traveled outside U.S./Canada (where and when)

Recent medical test/lab work results

Family History

Relationship	Alive/Deceased	Present Health or Cause of Death
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Father
Mother
Brothers
Sisters
Children/Ages

Medications & Supplements

Name	Dosage	Frequency	Length of Time	Reason for Taking

Lifestyle

Sexual Activity
Socializing w/Friends
Relaxation/Self Pampering
Tobacco
Recreational Drugs
Teeth Flossing

Stress

On a scale of 1–10, how stressful is your:

Work

Social/Family Situation

Current Health Status

Life in General

Do you feel that your current state of health is:

Largely in your controlLargely out of your control

What can you do to make a difference in your current health status?

What 1–2 key steps have you already taken?

Significant Life Events

Date	Event

Metabolic Screening Questionnaire

Rate each symptom based on your health for the past 30 days
(0 = Never or almost never have the symptom., 1 = Occasionally have it; effect is not severe., 2 = Occasionally have it; effect is severe., 3 = Frequently have it; effect is not severe., 4 = Frequently have it; effect is severe.).

Nausea or vomiting
Diarrhea

Symptom Questionnaire

Section 1

Indigestion, burping, bloating or sleepy immediately after meals
Heartburn or acid reflux symptoms
Tendency to allergies, eczema, asthma
Nausea in evenings
Proteins hard to digest, complex meals hard to digest (combination of proteins and carbs)
Loss of taste for meat
Sense of excess fullness after meals
Feel like skipping breakfast, overall low appetite
Undigested food in stool
Anemia, unresponsive to iron

Section 2

Heartburn or acid reflux symptoms
Nausea in mornings
Strong appetite, demanding hunger, excess salivation
Aggravated by spice or sour, sour burps, sour smell

Section 3

Pain between shoulder blades
Stomach upset by fatty or fried foods
Loose stools with fatty foods, irregular stools, fat in stools (shiny, floating), smelly stools
Nausea
Light, clay colored or greenish/yellow stools
Dry skin, itchy feet or skin peels on feet
Gallbladder attacks
Gallbladder removed
Bitter taste in mouth, especially after meals
Easily intoxicated or hung if you were to drink wine
Pain under right side of rib cage
Hemorrhoids or varicose veins
Sensitive to chemicals (perfume, cleaning agents, etc.), diesel fumes or tobacco smoke

Section 4

Food allergies or sensitivities (wheat or grain, or dairy or other)
Frequent intake of allergenic food(s), strong attachment to allergenic foods
Craving, addiction or binging of allergenic foods(s)
Abdominal bloating 1-2 hours after eating
Pulse speeds up after eating
Crohn’s disease, frequent sinus infection, migraines, asthma
Airborne allergies
Experience hives

Section 5

Catch colds at the beginning of winter
Frequent colds, flu or other infections (sinus, ear, bladder, skin, etc.)
Experienced a mucous producing cough
Never get sick
History of Epstein Bar, Mono, Herpes, Shingles, Chronic Fatigue Syndrome, Hepatitis, or other chronic viral conditions
Have food allergies or sensitivities

Section 6

Coating on your tongue
Anus itches
Fungus or yeast infections
Yeast symptoms increase with sugar, starch or alcohol consumption
Less than one bowel movement a day
Constipation, stools hard or difficult to pass
Excessive foul smelling lower bowel gas
Irritable bowel or mucous colitis
Bad breath or strong body odor
Cramping in lower abdominal region
Stools are difficult to pass
History of parasites
Stools have corners or edges, are flat and ribbon shaped

Section 7

Eat less than five servings of (one-half cup cooked, 1 cup raw) of colored vegetables or fruits a day
Crave sweets, breads, rolls, cookies, pasta, pizza or chips
Crave coffee or sugar in the afternoon
Sleepy in the afternoon
Fatigue is relieved by eating
Binging or uncontrolled eating
Excessive appetite
When you eat snacks/sweets, do you eat them, get a temporary boost of energy and mood, and later crash?
Headache, irritability or shakiness if meals are skipped or delayed
Heart palpitations after eating sweets
Have frequent thirst
Have frequent urination
Once you start eating sweets or carbohydrates, do you feel you can’t stop
Tend to gain weight in the belly
Have pre-diabetes, diabetes, PCOS, hypoglycemia or alcoholism or a family history of any one of these
Have elevated triglycerides or cholesterol
Have high blood pressure

Section 8

Have high or low blood pressure
Have a low libido
Have trouble falling asleep
Get less than 8 hours a sleep a night
Go to bed frequently after midnight
Get less than 1 hour a day of sunlight
Work the night shift
Are you an emotional eater
Feel anxious or have panic attacks
Are you a shallow breather
Experience heart palpitations
Cravings for salt or sweets
Experience chronic or prolonged fatigue
Does fatigue prevent you from doing things you would like to do. Interfere with your work, family or social life
Do you feel you can’t get started in the morning without coffee or caffeinated drinks

Section 9

Are you cold when everyone else is warm
Have coarse or brittle hair
Experience constipation
Have thinning hair or hair loss
Experienced a loss of sex drive
Lost the outside of your eyebrow
Experience depression
Have trouble losing weight
Have a low blood pressure or heart rate
Have elevated cholesterol
Have a hoarse voice
Have dry, scaly skin
Have cold hands and feet
Experience fatigue
Experience fluid retention

Section 10

Aware of irregular or heavy breathing
Experienced discomfort at high altitudes
Sigh frequently or “air hunger”
Have shortness of breath with moderate exertion
Experience swelling of the ankles, especially at end of day
Blush or face turns red for no reason
Experience a dull pain or tightness in chest and/or radiate into left arm, worse on exertion
Have muscle cramps on exertion

Section 11

Rarely break out into a sweat
Use aluminum cooking equipment
Have mercury amalgams
Heat food in plastic containers in microwave
Have your clothes dry-cleaned
Eat “fast-food” > 2 times a week
Drink tap, well or bottled water
Have strong body odor
Have acne on face or buttocks
Drink < 4 cups water a day (approximately 30 oz)
Live in a large urban or industrial area
Use lawn or garden chemicals
Have less < 1 bowel movement per day
React to small amounts of alcohol
Sit on your computer 3+ hours a day
Exercise < 3 times a week
Use tobacco products
Eat large fish (sword fish, tuna, shark, tilefish) more than once a week
Urinate small amounts of dark urine only a few times a day
Frequently exposed to solvents and chemicals at work or at home
Feel any of the following: wired, increased aches in muscles and joints, anxiety, palpitations, sweating, dizziness when using caffeine
Have a negative reaction when you consume foods containing MSG, sulfites or other preservatives

Nutrition Frequency

Food/Drink	Select Frequency	Comments
Caffeine
Soda/Soft Drinks

How many times each week do you eat each meal at home (vs. out)?

Approximately how many ounces of water do you drink per day?